Study Ch. 6, 7, 19

Dietary Considerations for Patients With an Ileostomy or Colostomy

Foods that May Cause Gas: Alcohol and beer Carbonated beverages Chewing gum Chives Cucumbers Dried peas, beans, and lentils Eggs Fried food (some) Most fruits Oat bran and other foods high in soluble fiber Onions Pasta, noodles Peppers Pickles Sauerkraut Vegetables from the cabbage family. The carbohydrate raffinose in these foods is poorly digested and leads to gas. This includes foods such as broccoli, Brussels sprouts, cabbage, cauliflower, and turnips. Foods that May Cause Stomal Blockage: Bean sprouts Cabbage Carrots (raw) Celery Coconut Corn Cucumbers Dried fruit Green pepper skin Lettuce Mushrooms Nuts Olives Peas Pickles Pineapple Popcorn Seeds Skins and seeds from fruits and vegetables Spinach Foods that May Help to Control Diarrhea: Applesauce Bananas Cheese Creamy peanut butter Oatmeal or oat bran Potatoes Soda crackers Starchy foods (rice, pasta, barley) Tapioca Yogurt Foods that Produce Odor Asparagus Dried peas, beans, and lentils Eggs Fish Garlic Onions Some spicy foods Turnip Foods that are Natural Intestinal Deodorizers: Buttermilk Parsley Yogurt

Good Samaritan Laws

Good Samaritan laws are designed to protect health care providers when they give aid to people in emergency situations. For example, a nurse at the scene of an automobile accident may give emergency care without fear of a legal suit if such care appears necessary, unless care is given in a grossly negligent manner. Every state in the United States and the District of Columbia has Good Samaritan laws, although the laws vary considerably. Nurses are covered in some states but not in others; in some states, only certain acts are covered. While in many states no person has a legal obligation to help another (except in employment situations), and a health care provider, like any other person, may choose to help or to leave the scene of an emergency, other states consider it mandatory for anyone to give help. Refer to the specific laws in your state. Regardless, in many situations, nurses may have an ethical responsibility to assist. In the event that health care providers assist a person in an emergency situation when it is impossible to obtain consent for the care, they are expected to use good judgment to determine that an emergency exists and to give care that a reasonably prudent person with a similar background and in similar circumstances would provide.

Chapter 37 Key Concepts

- The kidneys help maintain the composition and volume of body fluids. The kidneys filter and excrete blood constituents that are not needed and retain those that are. Body fluids remain relatively stable if the kidneys are functioning properly. Urine—the waste product excreted by the kidneys—contains organic, inorganic, and liquid wastes. - The nephron is the basic structural and functional unit of the kidneys. - Urine is transported from each kidney by the ureters to the urinary bladder. - The urinary bladder is a smooth muscle sac that serves as a temporary reservoir for urine. - The urethra conveys urine from the bladder to the exterior of the body. - The process of emptying the bladder is known as urination, micturition, or voiding. - Any involuntary loss of urine that causes a problem is referred to as urinary incontinence. - Urinary retention occurs when urine is produced normally but is not excreted completely from the bladder. - Factors affecting the amount and quality of urine produced by the body and the manner in which it is excreted include developmental considerations, food and fluid intake, psychological variables, activity and muscle tone, pathologic conditions, and medication use. - Nursing assessment of urinary elimination includes collection of data about the patient's voiding patterns, habits, and difficulties, along with a history of current or past urinary problems; physical examination of the bladder, if indicated, and urethral meatus; assessment of skin integrity and hydration; examination of the urine and measurement of urine volume; and correlation of these findings with the results of diagnostic tests and procedures for examining the urine and the urinary tract. - Nurses use different techniques for collecting urine specimens. The nurse needs to understand the rationale for the specific test ordered, as well as the correct collection procedure associated with the required test in order to ensure obtaining the appropriate urine sample. - Nurses are responsible for preparing the patient for diagnostic procedures related to urinary function and giving appropriate aftercare. - The data collected about the patient's urinary functioning may lead to one or more nursing diagnoses. - Nursing outcomes related to urinary elimination include the following: the patient will produce urine output about equal to fluid intake; maintain fluid and electrolyte balance; empty the bladder completely at regular intervals; report ease of voiding, as appropriate; and maintain skin integrity. - Nursing interventions focus on maintaining and promoting normal urinary patterns, improving or controlling urinary incontinence, preventing potential problems associated with bladder catheterization, assisting with care of urinary diversions, and care of vascular access for hemodialysis and peritoneal dialysis. - Patient education is essential for independence in self-care related to urinary elimination. - The nurse evaluates the effectiveness of a care plan to promote healthy urinary functioning by checking whether the patient has met the individualized patient goals specified in the plan

Ch. 6 Key Concepts

- Values are beliefs about the worth of something and are formed during a lifetime, influenced by the environment, family, and culture. Values essential to the professional nurse include altruism, autonomy, human dignity, integrity, and social justice. - Nurses can use the process of values clarification to help themselves and patients come to understand their own values and value systems to guide their decision making. - Ethics is the systematic inquiry into principles of right and wrong conduct, of virtue and vice, and of good and evil as they relate to conduct and human flourishing. Examples of types of ethics include bioethics, clinical ethics, and nursing ethics. - Ethical theories or frameworks are systems of thought that attempt to answer how we ought to live and why. Theories are broadly categorized as action or character guiding. - The principles-based approach to ethics offers specific action guides such as autonomy, beneficence, nonmaleficence, and justice. Other principles highly valued by nurses include fidelity, veracity, accountability, privacy, and confidentiality. - The care-based approach to ethics prioritizes the nurse-patient relationship and directs nurses to respond to the vulnerabilities of patients as well as cultivate virtues such as kindness, attentiveness, empathy, compassion, and reliability. - Nurses learn to practice ethical conduct by cultivating the virtues of nursing, understanding ethical theories that dictate and justify professional conduct, and becoming familiar with codes of nursing ethics and standards for professional nursing conduct. - Bills of rights exist for both patients and registered nurses. - Nurses can use the nursing process to guide ethical decision making. Ethically relevant considerations include a balance between benefits and harms in the care of patients; disclosure, informed consent, and shared decision making; norms of family life; the relationship between clinicians and patients; the professional integrity of clinicians; cost effectiveness and allocation of care; issues of culture and religious variation; and considerations of power. - Patient advocacy is central to the roles and identity of professional nursing. Advocacy may involve political activism or whistle-blowing.

List guidelines for effective documentation: Content, timing, format, accountability, confidentiality

1. Content- enter information in a complete, accurate, concise, current, and factual manner. Record patient findings. Avoid "good," "average," "normal," or "sufficient." 2. Timing- document in timely manner according to agency policy. Document interventions but never before carrying out the intervention. 3. Format- check for correct chart before documenting. Use standard terminology. Date and time each entry; record chronologically 4. Accountability- sign first, last name, and title to each entry; draw single line through mistakes and write "mistaken entry" or "error in charting." Records are permanent! 5. Confidentiality- moral and legal right for privacy; students are bound to privacy. Actual names should never be used. IN DEPTH: Aim: Complete, accurate, concise, current, factual, and organized data communicated in a timely and confidential manner to facilitate care coordination and serve as a legal document. Content - Enter information in a complete, accurate, concise, current, and factual manner. - Make sure your documentation reflects the nursing process and your professional responsibilities. - Record patient findings (observations of behavior) rather than your interpretation of these findings. - Avoid words such as "good," "average," "normal," or "sufficient," which may mean different things to different readers. - Avoid generalizations such as "seems comfortable today." A better entry would be "on a scale of 1 to 10, patient rates back pain 2 to 3 today as compared with 7 to 9 yesterday; vital signs returned to baseline." - Note problems as they occur in an orderly, sequential manner; record the nursing intervention and the patient's response; update problems or delete as appropriate. - Record precautions or preventive measures used. - Document in a legally prudent manner. Know and adhere to professional standards and facility/institutional policy for documentation. - Document the nursing response to questionable medical orders or treatment (or failure to treat). Factually record the date and time the health care provider was notified of the concern and the exact health care provider response. If this occurs by phone, have a second nurse listen to the conversation and cosign the note. If a nurse administrator was contacted, document this. Documentation should give legal protection to the nurse, other caregivers, the health care facility or institution, and the patient. - Avoid stereotypes or derogatory terms when charting. - Refrain from copying and pasting notes in an EHR, because the data may be outdated or inaccurate. Timing - Document in a timely manner. Follow facility policy regarding the frequency of documentation and modify this if changes in the patient's status warrant more frequent documentation. - If you forget to document something, record it as soon as you can, following the procedures for making late entries. Example: Late entry: Patient reported passing gas at 8:00 AM this morning but no stool yet. Notified the surgical resident, Dr. Cotter—C. Taylor, RN. - Indicate in each entry the date and both the time the entry was written and the time of pertinent observations and interventions. This is crucial when a case is being reconstructed for legal purposes. - Most facilities use military time, one 24-hour time cycle, to avoid confusion between AM and PM times - Document nursing interventions as closely as possible to the time of their execution. The more seriously ill the patient, the greater the need to keep documentation current. Never leave the unit for a break when caring for a seriously ill patient until all significant data are recorded. - Never document interventions before carrying them out. - Write a progress note for each of these instances: ---- Upon admission, transfer to another unit, and discharge ----When a procedure is performed ----Upon receiving a patient postoperatively or postprocedure ----Upon communicating with health care providers regarding critical patient information (e.g., abnormal lab value result) - For any change in patient status Format - Check to make sure you have the correct chart before writing. - Record on the proper form or screen as designated by facility policy. - With paper charts, print or write legibly in dark ink to ensure permanence. Use correct grammar and spelling. Use standard terminology, only commonly accepted terms and abbreviations, and symbols. Alternately, follow computer documentation guidelines. - Date and time each entry. - Record nursing interventions chronologically on consecutive lines. Never skip lines. Draw a single line through blank spaces. Accountability - Sign your first initial, last name, and title to each entry. Do not sign notes describing interventions not performed by you that you have no way of verifying. - Do not use dittos, erasures, or correcting fluids. Draw a single line through an incorrect entry, and write the words "mistaken entry" or "error in charting" above or beside the entry and sign. Then rewrite the entry correctly. - Identify each page of the record with the patient's name and identification number. - Recognize that the patient record is permanent. Follow facility policy pertaining to the color of ink and the type of pen or ink to be used. Ensure that the patient record is complete before sending it to medical records. Confidentiality - Patients have a moral and legal right to expect that the information contained in their patient health record will be kept private. Students should be familiar with facility policy and pertinent legislation about who has access to patient records other than the immediate caregiving team, and the process used to obtain access (see HIPAA guidelines). - Most facilities allow students access to patient records for educational reasons. Students using patient records are bound professionally and ethically to keep in strict confidence all the information they learn by reading patient records. Actual patient names and other identifiers should not be used in written or oral student reports.

Identify measures to protect confidential patient information.

1. Make sure computer screens face away from public areas. 2. Use encryption software when sending email over public networks. 3. Request separate printers for specific units. 4. Use secure disposal containers by copiers 5. Use phones with built in encryption 6. Restrict use of voice pagers 7. Verify fax numbers before transmitting.

Contracts

A contract is an exchange of promises between two parties. The agreement may be in writing or oral, although oral contracts may be more difficult to prove. The law of contracts provides a remedy for a breach of contract so that the person who suffers from a broken contract may be compensated for any resulting loss. For a contract to be legally enforceable, it must involve real consent of the parties, a valid consideration, a lawful purpose, competent parties, and the format required by law. Practicing nurses enter into legally valid and binding contracts with both their employers and their patients. Thus, it is important to understand and be able to fulfill the terms of a nursing agreement before agreeing to a contract. Your employment contract should specify what it is reasonable for you to expect of your employer and what the employer can expect of you. An employer that repeatedly expects you to assume supervisory responsibilities without benefit or who fires you without just cause is likely to be guilty of contract violations. Similarly, you may be guilty of contract violations if you refuse to accept reasonable assignments, repeatedly fail to arrive on time for work, or are habitually unable to complete reasonable work assignments. Any action by your employer that violates a federal or state law is the basis of a grievance, even if the employment contract permits the action. Examples include a female nurse receiving less pay for performing the same work as a male nurse, or a supervisor's failure to promote an employee based on race. When discrimination is suspected, complaints should be filed with the Equal Employment Opportunity Commission (EEOC). Contracts with patients are often implied. There may not be a written contract specifying what is reasonable for patients to expect of nurses, but courts will uphold an implied contract obligating the nurse to be competent and to provide responsible care.

Crimes and Torts

A wrong committed against a person or that person's property may be categorized as a crime or a tort, or sometimes both. A crime is a violation punishable by the state, whereas a tort is subject to action in a civil court with damages usually being settled with money. By its very nature, a wrong tried as a crime is considered a more serious offense, with more legal implications, than a tort Crime Though there may only be one victim of a crime, criminal acts are considered to be against the public as well. In a criminal case, the government, called "the people," prosecutes the offender. When a crime is committed, the factor of intent to commit wrong is present in most cases. Nonetheless, people who break certain laws are guilty of a crime regardless of whether they intended it. For example, failure to observe the Federal Food, Drug, and Cosmetic Act may constitute a crime. Criminal law is in most cases statutory law (e.g., Federal Controlled Substance Acts and kidnapping laws or state criminal codes that define murder, manslaughter, criminal negligence, rape, fraud, illegal possession of drugs, theft, assault, and battery); only infrequently is it common law. Examples of common law are informed consent and the right to refuse treatment. Crimes are further classified as misdemeanors or felonies. A misdemeanor is a less serious crime, commonly punishable with a fine, imprisonment for less than 1 year, or both, or with parole. A felony (e.g., rape, murder) is punishable by imprisonment in a state or federal penitentiary for more than 1 year. Torts Torts may be intentional or unintentional acts of wrongdoing. Some of the intentional torts for which nurses may be held liable include assault and battery, defamation of character, invasion of privacy, false imprisonment, and fraud. A person committing an intentional tort is considered to have knowledge of the permitted legal limits of his or her words or acts. Violating these limits is grounds for prosecution. For example, although a policy specifies that a nurse may use restraints to protect an incompetent patient, restraining a competent patient to administer medications forcefully while the patient is refusing is assault and battery. Unintentional torts are referred to as negligence. A nurse who fails to initiate proper precautions to prevent patient harm (e.g., falls, skin breakdown) is subject to the charge of negligence. The nurse may not intend to cause harm, but harm results nevertheless. An act that is a tort may also be a crime. For example, gross negligence demonstrating that the offender is guilty of complete disregard for another's life may be tried as both a civil and criminal action. It is then prosecuted under both civil and criminal law.

Use an ethical framework and decision-making process to resolve ethical problems.

ADPIE Step 1: Assess the Situation (Gather Data). - Recognize and then describe the situation and contextual factors that give rise to the ethical problem. This involves the main people involved (their views and interests); the patient's overall nursing, medical, and social situation; and relevant legal, administrative, and staff considerations. Step 2: Diagnose (Identify) the Ethical Problem. - Clarify that the issue is ethical in nature: (1) Is there a conflict at the personal, interpersonal, institutional, or societal level? Is there a question that arises at the level of thought or feeling? (2) Does the question have a moral or ethical component? Why? For example, does it raise issues of rights, moral character? State the problem clearly. Identify your relationship to the decision. Identify time parameters. Make sure that the problem is an ethical problem rather than a communication or legal problem. Some suggest that whenever human dignity is being threatened, you have an ethical problem. Step 3: Plan (Identify and Weigh Alternatives). - Identify options and explore the probable short-term and long-term consequences of each for each stakeholder. Use ethical reasoning to decide on a course of action that you can justify ethically: Identify your personal and professional moral positions and values and those of other involved people. Apply pertinent ethical theories and principles. Apply codes of conduct and ethics, professional position statements or guides, and institutional policies as applicable. Consider consulting with a respected and wise colleague or an institutional ethics committee or consultant. Decide on the course of action that you are best able to support. Step 4: Implement Your Decision. - Implement your decision and begin to compare the outcome of your action with what you considered and hoped for in advance. Step 5: Evaluate Your Decision. - What have you learned from this process that will help you in the future? How can you improve your reasoning and decision making in the future? In what ways does your institutional culture need to change to prevent similar conflicts in the future? IN SUMMARY: Assess the situation (gather data). Diagnose (identify) the ethical problem. Plan: o Identify options. o Think ethical problem through. o Make a decision. Implement your decision. Evaluate your decision.

Professional Liability Insurance

Although a nurse's best legal safeguard is always competent practice, the increasing number of malpractice claims naming nurses as defendants makes it wise for nurses to carry their own liability insurance. Nurses may obtain this insurance through the ANA and other nursing associations, as well as from other sources. Reasons the ANA (1990) lists for purchasing a personal professional liability insurance policy are as follows: - Protection of the nurse's best interests. If the nurse is named as a defendant in a malpractice action along with the facility, a conflict of interest could arise between the nurse and the facility. Nurses have no assurance that their best interest will be represented unless they have their own coverage, which provides their own attorney. - Limitations of employer's coverage. Most health care facilities carry "claims-made" insurance, which means that if the nurse is no longer working there or the facility closes, the nurse is not covered when a claim is filed. - Care or advice given outside of work. An employer's policy covers the nurse only within the confines of the work setting. Nurse attorney White (2011) explores the personal, professional, and historical influences on why nurses should or should not have their own malpractice insurance. As well, White urges nurses to regularly evaluate their circumstances and decide not only whether to carry their own malpractice insurance but what kind and how much. Pohlman (2015) notes that an individual policy provides benefits not usually covered in employer policies, such as coverage for assault, first aid expenses, violations of the HIPAA, libel or slander, depositions, property damage, and license protection benefits.

Documentation

Although most nurses prefer to spend their time interacting with patients rather than documenting in a patient's record, careful documentation is a crucial legal safeguard for the nurse. Documentation must be factual, accurate, complete, and entered in a timely fashion. The law presumes that if something was not documented, it was not done. This includes even routine acts, such as taking vital signs, repositioning patients, and ensuring the patient's safety. In 2004, The Joint Commission created a list of "Do Not Use" abbreviations that should not be included in documentation. Be sure to check your facility's policies on what and how to document. Be sure that the nursing care plan is part of the patient's permanent record. Facilities should have flow sheets or a documentation form that enables you to check off routine aspects of care rapidly and completely. You should also write a comprehensive nursing note for each patient problem you address. This note should include the current nature of the problem, how you intervened, the patient's response, and, when appropriate, future priorities for care. After a problem is noted, nursing documentation should demonstrate continuity of care until the problem is resolved. A common problem reported by nurses is not knowing how to document a situation in which the nurse believes a patient needs medical attention but the responsible health care providers are not responding to calls for assistance. In this case, the best legal safeguard is to document the facts of the incident, being careful not to make incriminatory statements, such as "Anyone could see we were losing this patient rapidly" or "Once again, Dr. Jones was unavailable when her patient needed her." The note should document the time the health care provider was called, the time of response or lack of response, and the subsequent nursing response (e.g., nursing supervisor notified). Such a note documents that you are carefully assessing the patient, recognizing significant cues, and reporting them appropriately. The nursing supervisor should write the next note after reviewing the case and choosing a course of action. Patient's noncompliance with a treatment also should be documented, along with your attempts to increase compliance.

Checklist to Ensure Informed Consent

Disclosure Patient/surrogate has been informed of the (1) nature of the procedure, (2) risks (nature of the risk, magnitude, probability that the risk will materialize) and benefits, (3) alternatives (including the option of nontreatment), and (4) fact that no outcomes can be guaranteed. Comprehension Patient/surrogate can correctly repeat in his or her own words that for which the patient/surrogate is giving consent. Competence The patient understands the information needed to make this decision, is able to reason in accord with a relatively consistent set of values, and can communicate a preference. The surrogate (if needed) meets the above criteria, knows the patient's wishes to the extent that this is possible, and is free from undue emotional stress and conflict of interests. Voluntariness The patient is voluntarily consenting or refusing. Care has been taken to avoid manipulative and coercive influences.

Risk Management Programs

Hoping to reduce malpractice claims, many health care facilities have initiated risk management programs designed to identify, analyze, and treat risks. Elements of a comprehensive risk management program include the following: - Safety program. The aim is to provide a safe environment in which the basic safety needs of patients, employees, and visitors are met. - Product safety program. The aim is to ensure safe and adequate equipment; this involves ongoing equipment evaluation and maintenance. - Quality assurance program. The aim is to provide quality health care to patients; this involves ongoing evaluation of all systems used in the care of patients. Nurses with legal questions often find risk managers a helpful resource. Many risk managers encourage nurses and other clinicians to report "near misses" to better identify factors contributing to errors. A "near miss" is an error that would have happened except for someone's alertness and ability to identify and prevent the error.

Whistle Blowing

Many nurses who are frustrated with unsafe practice environments are speaking up. Whistle-blowing is a warning from a present or past member of an organization to the public concerning a serious wrongdoing or danger created or masked by the organization. The decision to whistle-blow can be difficult, since some nurses have been threatened with the loss of their jobs and licenses. Whistle-blower laws are intended to prevent employers from taking retaliatory action against nurses, such as suspension, demotion, harassment, or discharge, for reporting improper patient care or business practices. As part of the ANA Nationwide State Legislative Agenda, the ANA and State Nurses Associations are promoting strong whistle-blower laws on the state level that provide legal protections for nurses advocating for patients without fear of reprisal. Many states now have protections in other legislation such as safe staffing and mandatory overtime prohibition.

Executing Provider Orders

Nurses are legally responsible for carrying out the orders of a legitimate provider in charge of a patient unless a reasonable person would anticipate the order would lead to injury. Follow these guidelines: 1) Be familiar with the parties designated in your state's nurse practice act who can legally write orders for the nurse to execute. (For example, in many states, a physician assistant cannot legally write orders for the nurse.) 2) Be familiar with your institution's or facility's policy regarding provider orders. 3) Attempt to get all provider orders in writing. Verbal orders (VOs) and telephone orders (TOs) should be countersigned within 24 hours. Take the following steps to prevent errors caused by TOs: - Limit TOs to true emergency situations when there is no alternative. - Designate which nurses may take TOs (e.g., those who have more education and experience). -Repeat the TO back to the provider for confirmation. - Document the order, its time and date, the situation necessitating the order, the provider prescribing and reconfirming the order as it is read back, and your name. Indicate if the order is a VO or TO. - When possible, have two nurses listen to a questionable TO, with both nurses countersigning the order. See Chapter 19 for additional guidelines on executing verbal, telephone, and fax orders. 4) The Joint Commission (2016b) now permits licensed independent health care providers to send orders via text messaging "as long as a secure text messaging platform is used and the required components of an order are included." 5) Question any health care provider order that is: - Ambiguous - Contraindicated by normal practice (e.g., an abnormally high dose of medication) - Contraindicated by the patient's present condition (e.g., as a patient's present condition improves, the patient may no longer need aggressive forms of treatment)

Describe nursing interventions that can be used to manage urinary incontinence effectively. Types - Stress, Urge

PFMT (kegel) help ambulate easy access to bathroom maintain fluid intake discourage use of alcohol and caffeine biofeedback Behavioral Techniques - Pelvic floor muscle training exercises: Pelvic floor muscle training (PFMT) exercises (Kegel exercises) can be used to strengthen pelvic floor muscles and sphincter muscles. PFMT exercises can be done alone, with weighted cones, or with biofeedback. - Biofeedback: Measuring devices are used to help the patient become aware of when pelvic floor muscles are contracting. - Electrical stimulation: Electrodes are placed in the vagina or rectum that then stimulate nearby muscles to contract. - Timed voiding or bladder training: May be used with biofeedback. Patient keeps track of when voiding and leaking occur to enable oneself to plan when to void, with increasing length of voiding intervals. Bladder training involves biofeedback and muscle training. Urgency control is addressed using distraction and relaxation techniques. Pharmacologic Treatment - Treatment is dependent on the type of incontinence. Some medications inhibit contractions of the bladder, others may relax muscles, and some tighten muscles at the bladder neck and urethra. - Topical estrogen may be used in postmenopausal women to relieve atrophy of involved muscles. - Collagen may be injected into the tissue around the urethra to add bulk and help close the urethral opening. Mechanical Treatment - Pessaries: A stiff ring that is inserted into the vagina, where it helps to reposition the urethra. The pessary may be placed by the patient or by a nurse. - External barriers: Adhere to the urethral opening to stop urine leakage. The barrier is a small foam pad placed over the urethral opening. It seals against the body to keep urine from leaking. It is removed and discarded before the patient voids. - Urethral insert: Small device, like a plug, that fits into the urethra. Removed to void, the insert is replaced until the patient needs to void again. Surgical intervention: Used as a last resort. Type of surgery depends on cause of incontinence.

perform catheterizations; and assist with urinary diversions.

Patient Education: - Explain reason for diversion and rationale for treatment - Demonstrate effective self-care behaviors - Describe follow-up care and support resources - Report where supplies may be obtained in the community - Verbalize related fears and concerns - Demonstrate a positive body image Urinary catheterization is the introduction of a catheter (tube) through the urethra into the bladder for the purpose of withdrawing urine. When voluntary control of urination is difficult or not possible for male patients, an alternative to an indwelling catheter is the urinary sheath or external condom catheter. This soft, pliable sheath made of silicone material is applied externally to the penis and directs urine away from the body. Most devices are self-adhesive. The external urinary catheter is connected to drainage tubing and a collection bag, and can be used with a leg bag Before the catheterization, explain to the patient the procedure and the reason for it. Tell the patient that catheter insertion produces a sensation of pressure and some discomfort. Explain that measures will be taken to avoid exposure and embarrassment. The more relaxed the patient is, the easier it will be to insert the catheter. The most common patient position for catheter insertion is the dorsal recumbent position, with the patient preferably on a solid surface, such as a firm mattress or a treatment table. Catheterizing a patient in a bed with a soft mattress, especially a female patient, is not as satisfactory because the patient's pelvic surfaces are not firmly supported and visualization of the meatus is difficult. Also, the patient may sink into the bed, causing the bladder to be lower than the outlet of the catheter. If the patient is in bed, supporting the buttocks on a firm cushion is helpful.

Describe nursing interventions that can prevent the development of urinary tract infections. Who is at risk?

Patients at risk for UTIs -Sexually active women -Women who use diaphragms for contraception -Postmenopausal women -Individuals with indwelling urinary catheter -Individuals with diabetes mellitus -Older adults Instruct the patient to: - Drink 8 to 10 8-oz glasses of water daily. - Observe the urine for color, amount, odor, and frequency. Report any sign of infection to your health care provider. - Dry the perineal area after urination or defecation from the front to the back, or from the urethra toward the rectum. - Drink two glasses of water before and after sexual intercourse and void immediately after intercourse. - Take showers rather than baths. - Wear underwear with a cotton crotch, and avoid clothing that is tight and restrictive on the lower half of the body. encourage shower encourage perineal care avoid using irritating feminine products maintain liberal fluid intake

Patients' Rights

Patients' Rights The American Hospital Association developed "A Patient's Bill of Rights" in 1972 (revised in 1992 and 2003). Renamed "The Patient Care Partnership" (Box 7-6 on page 140), it addresses the expectations, rights, and responsibilities of the patient while receiving care in the hospital, and ranges from "high-quality hospital care" to "helping prepare you and your family for when you leave the hospital." With care moving increasingly from the hospital to the community, legally prudent nurses must be familiar with how different institutions and professional groups define patient rights and responsibilities. Other bills of rights include the Pregnant Patient's Bill of Rights, the Indian Patient's Bill of Rights, a Nursing Home Bill of Rights, and the Veterans Administration Code of Patient Concern. Each emphasizes a specific aspect of patient rights within a particular health facility and implies a code of ethics that the nurse observes professionally.

Collective Bargaining

The 2015 ANA Code of Ethics for Nurses states that the nurse, "through individual and collective effort, establishes, maintains and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care." Although individual contracts serve many nurses adequately, many nurses have joined other groups of workers whose interests are better protected when contracts are negotiated for them as a group. Collective bargaining is a legal process in which representatives of organized employees negotiate with employers about such matters as wages, hours, and conditions. Arbitration, strikes, and threats of strikes may be used to enhance the terms of employment and to enforce contracts. Many nurses choose their state nurses' association, rather than a trade organization, as their collective bargaining representative. Other nurses question whether collective bargaining is an appropriate role for a professional organization. When deciding whether to participate in collective bargaining, ask yourself the following questions: Will collective bargaining help my professional and economic status? Can I address my professional concerns through collective bargaining? Can I devote the time and effort that such organized activity demands? Can I change my working conditions as a person, or do I need to organize with other nurses to bring about the desired change?

Describe nursing practice that is consistent with the code of ethics for nursing.

The ANA Code of Ethics for Nurses serves the following purposes: - It is a succinct statement of the ethical obligations and duties of every person who enters the nursing profession. - It is the profession's nonnegotiable ethical standard. - It is an expression of nursing's own understanding of its commitment to society. Virtues are human excellences, cultivated dispositions of character and conduct that motivate and enable us to be good human beings. Clinical virtues enable nurses to provide good care to patients. While there is no official list of essential virtues of nurses, the following virtues are frequently named: -Competence -Compassionate caring -Subordination of self-interest to patient interest -Self-effacement -Trustworthiness -Conscientiousness -Intelligence -Practical wisdom -Humility -Courage -Integrity

Describe the nurse's role in communicating with other health care professionals by reporting

The Institute for Healthcare Improvement is promoting the ISBAR communication technique as a framework for communication between members of the health care team about a patient's condition: 1) Identity/Introduction: Communicate who you are, where you are, and why you are communicating. 2) Situation: Communicate what is occurring and why the patient is being handed off to another department or unit. 3) Background: Explain what led up to the current situation and put in context if necessary. 4) Assessment: Give your impression of the problem. 5) Recommendation: Explain what you would do to correct the problem. Note that there are different ISBAR formats: earlier versions used simply SBAR, and some newer versions use ISBARR, with the last R being a read-back of orders/response. ISBARR1. Identity/Introduction- state name, title, unit. 2. Situation- I am calling about (patient name and room #) The problem I am calling about is: 3. Background- state admission diagnosis and admission date; state pertinent medical history; brief synopsis of treatment; most recent vitals; changes in vital signs or assessment from prior assessment 4. Assessment- give conclusions; use words like "might be" or "could be"; indicate what body systems are involved if situation is unclear 5. Recommendation- say what you think would be helpful or needs to be done; ask about changes in orders 6. Read back of orders/response- restate given orders; clarify how often to do vital signs; under what circumstances to call back

facilitate use of the toilet, bedpan, urinal, and commode

Toilet Even when the patient can use the bathroom toilet, the nurse may be responsible for noting any abnormalities of urinary elimination. - In some instances, patients may be taught to report abnormalities to the nurse and instructed not to flush the toilet until the nurse checks the urine. In other instances, when the urine volume is to be calculated, the patient may need to urinate in a urinal or a specimen hat placed in the toilet so that the urine can be measured before it is discarded - Although many patients can easily be taught to measure their urine output, the nurse is responsible for observing urine at least once during a shift in acute care and more frequently if warranted. Assist weakened patients to the bathroom. If there is any danger of the patient falling, remain in attendance. Never lock the bathroom door. Also, ensure that a signal bell is within easy reach so that the patient can summon help easily if feeling weak and needing assistance. A handrail near the toilet also is helpful. Commode Commodes are chairs—straight-back chairs or wheelchairs with open seats and a shelf or a holder underneath that holds a bucket. Commodes can be used for patients who can get out of bed but cannot use the bathroom toilet. The commode can be placed adjacent to the bed, and the patient can be assisted to it with minimal exertion. If the patient has a roommate, any visitors may be asked to exit the room while the patient uses the commode. Remember to pull the curtain in the room and close the door to provide for patient privacy. Bedpan and Urinal Male patients confined to bed usually use the urinal for voiding and the bedpan for defecation; female patients use the bedpan for both. - Many patients find it embarrassing and difficult to use the bedpan and/or the urinal. When a patient uses a bedpan or urinal, maintain the patient's privacy. - A special bedpan called a fracture bedpan is frequently used by people with fractures of the femur or lower spine. Smaller and flatter than the ordinary bedpan, it is helpful for patients who cannot easily raise themselves onto the regular bedpan. Very thin patients or older adults often find it easier and more comfortable to use the fracture bedpan.

Identify approved abbreviations and symbols used for documentation and distinguish these from error-prone abbreviations and symbols. Table 19-3 DO NOT USE list

U, u (for unit) - Mistaken for "0" (zero), the number "4" (four), or "cc" - Write "unit" IU (International Unit) - Mistaken for IV (intravenous) or the number 10 (ten) - Write "International Unit" Q.D., QD, q.d., qd (daily) - Mistaken for each other - Write "daily" Q.O.D., QOD, q.o.d, qod (every other day) - Period after the Q mistaken for "I" and the "O" mistaken for "I" - Write "every other day" Trailing zero (X.0 mg)b - Decimal point is missed - Write X mg Lack of leading zero (.X mg) - Write 0.X mg MS - Can mean morphine sulfate or magnesium sulfate - Write "morphine sulfate" - Write "magnesium sulfate" - MSO4 and MgSO4 Confused for one another.

Adequate Staffing

Understaffing, sometimes called short staffing, is a problem that results in reduced quality of nursing care and may jeopardize patient safety. Temporary management solutions to understaffing, such as floating nurses from one unit to another, or asking (or mandating) nurses to work overtime or double (back-to-back) shifts, are ineffective because they can further jeopardize patient safety. A nurse in an understaffed facility will be held to a professional standard of judgment for accepting responsibility for work and for delegating nursing responsibilities to others. Thus, if a patient claims negligent care, a nurse claiming to have been overworked that evening because of an unrealistic assignment does not have adequate grounds for a legal defense. If patient injury results, the facility and nurse employee will most likely be named as codefendants. Some state nursing associations are using "protest of assignment forms" to track employer practices of routine understaffing.

Ostomy care Foods, Emptying, care/teaching

Changing the Ostomy Appliance - The ostomy appliance should protect the skin, collect the fecal discharge, and control odor. Typically, a colostomy does not produce drainage until normal peristalsis returns, usually within 2 to 5 days. An ileostomy drains within 24 to 48 hours because of the liquid contents in the small intestine. - For the first few days after surgery, most patients wear an open-ended appliance that allows for drainage of fecal material without removing the appliance. The skin barrier has an adhesive barrier that protects the surrounding skin from the stoma output. Appliances are either one-piece (barrier backing already attached to the pouch) or two-piece (separate pouch that fastens to the barrier backing). A transparent one-piece appliance is used in the initial postoperative period to allow for visualization of the stoma. - Appliances can be either drainable or closed. Empty a pouch that can be drained when it is one third full and replace it every 3 to 7 days, or whenever the seal comes away from the skin. Remove and change nondrainable pouches when they are half full. If an appliance is leaking from underneath the skin barrier, ring, or wafer, remove the bag, cleanse the skin, and apply a new bag. The procedure to change or empty an ostomy appliance is outlined in Skill 38-5 (on pages 1468-1473). The act of removing an appliance from the skin can result in skin stripping, which is removal of the outer, loosely bound, epidermal cell layers. This can be uncomfortable or even very painful for the patient. The cumulative effects of skin stripping over time can result in peristomal skin breakdown. The use of a silicone-based adhesive remover allows for the easy, rapid, and painless removal of a stoma pouch without the associated problems of skin stripping. A skin sealant may be used to protect the skin under the skin wafer or barrier Patient education is essential for independence in self-care. As the patient assumes responsibility for self-care, teach the patient how to make the necessary observations, to be aware of indications of problems, and to recognize when to seek assistance. For these goals to be met, the patient and/or family member needs to be able to do the following: - Explain the reason for bowel diversion and the rationale for treatment. - Demonstrate self-care behaviors that effectively manage the ostomy. - Describe follow-up care and existing support resources. - Report where supplies may be obtained in the community. - Verbalize related fears and concerns. - Demonstrate a positive body image. During the first 6 to 8 weeks after surgery, encourage the patient with an ostomy to avoid foods high in fiber (e.g., foods with skins, seeds, shells), as well as any other foods that cause diarrhea or excessive flatus, such as beans, cabbage, cauliflower, Brussels sprouts, and simple carbohydrates such as white flour and potatoes. By gradually adding new foods, the ostomy patient can progress to a normal diet. Urge patients to drink at least 2 quarts of fluids, preferably water, daily. EVALUATING: The nurse reflects on the effectiveness of a care plan to promote healthy bowel functioning by evaluating whether the patient has met the individualized patient goals specified in the plan. Adjustments in the nursing care plan are made accordingly. Nursing care is considered effective if the patient expresses satisfaction with the bowel elimination measures and is able to (as appropriate, based on specific behaviors and criteria individualized for the patient situation): - Verbalize the relationships among bowel elimination and nutrition, fluid intake, exercise, and stress management. - Develop a plan to modify any factors that contribute to current bowel problems or that might adversely affect bowel functioning in the future. - Promote bowel functioning as appropriate for the person. - Provide care for bowel diversion and know when to notify the primary care provider.

Demonstrate how to promote normal urination; facilitate use of the toilet, bedpan, urinal, and commode; perform catheterizations; and assist with urinary diversions.

Schedule Urge to void Privacy Position Hygiene Nursing care to promote normal urination includes interventions to support normal voiding habits, fluid intake, strengthening of muscle tone, stimulating urination and resolving urinary retention, and assisting with toileting. Goals: - Produce sufficient quantity of urine to maintain fluid, electrolyte, and acid-base balance. - Empty bladder completely at regular intervals without discomfort. - Provide care for urinary diversion and know when to notify physician. - Develop plan to modify factors contributing to current or future urinary problems. - Correct unhealthy urinary habits MAINTAINING NORMAL VOIDING HABITS If the patient's voiding habits are adequate, provide care or teach the patient to maintain these habits to ensure comfort and satisfactory urine output. Attention to the following variables is helpful: - Schedule: Some patients report urinating on demand in no apparent pattern. Others have inflexible patterns that have developed over the years and become anxious if these are interrupted. Some patients need assistance to urinate and may experience urgency. Nursing actions should support the patient's usual urinating pattern as much as possible. - Urge to void: Assist the patient to void when the patient first feels the urge to void. Routinely delaying urination may result in difficulty initiating a stream and/or urinary stasis. Urinary stasis can contribute to the development of UTIs. - Privacy: Many adults and children cannot urinate in the presence of another person. Unless the patient is extremely weak and requires assistance, provide privacy in the health care facility and in the home. - Position: Helping patients assume their usual voiding position may be all that is necessary to resolve an inability to urinate. Some male patients cannot use a urinal while lying down or sitting; encourage them to void while standing at the bedside unless this is contraindicated. Similarly, some female patients cannot void easily on a bedpan but respond favorably with a bedside commode. - Hygiene: Patients who are confined to bed find it difficult to perform their usual genital hygiene. Careful cleansing of the perineal and genital areas is needed for patient comfort and to prevent infection. This is easily accomplished for patients on bedrest by using warmed, moistened disposable washcloths and skin cleanser or by pouring warm, soapy water over the perineal area while the patient is still on the bedpan, followed by clear water. PROMOTING FLUID INTAKE - Many people routinely drink less fluid than is optimal to promote healthy urinary functioning. Adults with no disease-related fluid restrictions should drink 2,000 to 2,400 mL (8 to 10 8-oz glasses) of fluid daily. A common misperception is that drinking this much fluid causes water retention and contributes to weight gain. If a good proportion of the daily fluid intake is water, the kidneys and urinary structures are well flushed, and waste products, including potentially harmful bacteria, are removed. Monitor fluid intake for excessive amounts of caffeine-containing beverages, high-sodium beverages, and high-sugar beverages. Provide fresh water, juices, and fluids of preference to patients with alterations in mobility. Remind children and patients who are confused to drink. Fluid restrictions may be ordered for patients with certain health problems. For others, an above-average intake of fluids is prescribed. Incorporate this information in the care plan and provide patient education. STRENGTHENING MUSCLE TONE Weakening of the pelvic floor muscles is a common cause of urinary continence problems in women and men. PFMT can improve voluntary control of urination and significantly reduce or eliminate problems with stress incontinence (involuntary loss of urine related to an increase in intra-abdominal pressure) by strengthening perineal and abdominal muscle tone. - PFMT, often referred to as Kegel exercises, targets the inner muscles that lie under and support the bladder. These muscles can be toned, strengthened, and actually made larger by a regular routine of tightening and relaxing. Often patients have difficulty determining which muscles to exercise. These are the same muscles that the patient contracts to stop urinating in midstream or to control defecation. Instruct patients to contract the pelvic floor muscles for 10 seconds and to relax them for 10 seconds. - Encourage the patient to perform PFMT exercises without involving the muscles in the abdomen, inner thigh, and buttocks. When the patient is familiar with these sensations, these exercises should be performed multiple times a day for at least 3 months, and possibly longer, depending on the response. The exercises can be done anywhere. Assist patients to incorporate them into their daily activities. PFMT may be combined with biofeedback therapy or electrostimulation of the muscles PFMT can also be accomplished by using vaginal weights. The patient inserts a small weighted cone into her vagina. She then contracts her pelvic floor musculature to prevent the cone from falling out. The cones can be gradually increased in weight as the muscles are strengthened.

Delegating Nursing Care

the transfer of responsibility for the performance of an activity to another individual while retaining accountability for the outcome Professional nurses are responsible for delegating nursing activities, but although RNs may delegate elements of care, they do not delegate the nursing process itself. As a nurse, you remain accountable for any actions you delegate.

Ch 7 Key Concepts

- As the roles and duties of nurses expand, so does their legal accountability. Nurses who wish to avoid legal conflicts need to develop trusting nurse-patient relationships (satisfied patients rarely sue), practice within the scope of their competence, and identify potential liabilities in their practice and work to prevent them. - A law is a standard or rule of conduct established and enforced by the government that is intended chiefly to protect the rights of the public. Law may be public, private, civil, or criminal. Four sources of laws exist at both the federal and state level: constitutional law, statutory law, administrative law, and common law. - A lawsuit is a legal action in a court. Litigation is the process of bringing and trying a lawsuit. The person or government bringing a suit against another is called the plaintiff. The one being accused of a crime or tort is called the defendant. The defendant is presumed innocent until proved guilty of a crime or tort. - Each state has a nurse practice act that protects the public by broadly defining the legal scope of nursing practice. Nurse practice acts list the violations that can result in disciplinary actions against a nurse and also serve to exclude untrained or unlicensed people from practicing nursing. - Three processes are used for credentialing in nursing. The first is accreditation, the process by which an educational program is evaluated and recognized as having met certain standards. The second is licensure, the process by which a state determines that a candidate meets certain minimum requirements to practice in the profession and grants a license to do so. The third is certification, the process by which a person who has met certain criteria established by a nongovernmental association is granted recognition in a specified practice area. - A wrong committed against a person or that person's property may be categorized as a crime or a tort. A crime is a violation punishable by the state; a tort is subject to action in a civil court, with damages usually being settled with money. - Intentional torts include assault and battery, defamation, invasion of privacy, false imprisonment, and fraud. The Health Insurance Portability and Accountability Act (HIPAA) addresses privacy concerns. - Negligence and malpractice are unintentional torts. Liability involves four elements that must be established to prove that malpractice or negligence has occurred: duty, breach of duty, causation, and damages. The nurse may be involved in legal proceedings as a defendant, a fact witness, or an expert witness. - A variety of safeguards are in place in the health care system, both to protect nurses from exposure to legal risks while performing the duties of their role and to ensure that the practice environment is geared toward enhancing patient and personal safety. These safeguards include competent practice, informed consent or refusal, contracts, collective bargaining, patient education, safe execution of physician orders, safe delegation, legally prudent documentation, adequate staffing, whistle-blowing, professional liability insurance, risk management programs, incident reports, sentinel events, never events, the Patient's Bill of Rights, and Good Samaritan Laws. - As a student nurse, you are responsible for your own acts of negligence if these result in patient injury. Moreover, you are held to the same standard of care that would be used to evaluate the actions of a registered nurse. - Just as there are many safeguards in place to help protect nurses from the risk of legal action, there are many laws in place that govern the practice of nursing to protect both nurses and patients from harm. Such laws involve occupational safety and health, reporting obligations, controlled substances, discrimination and sexual harassment, patient privacy, use of restraints, nondiscrimination of people with disabilities, and other issues.

Incident, Variance, or Occurrence Reports

An INCIDENT REPORT, also called a variance or occurrence report, is used by health care facilities to document the occurrence of anything out of the ordinary that results in, or has the potential to result in, harm to a patient, employee, or visitor (Fig. 7-3). These reports are used for quality improvement and should not be used for disciplinary action against staff members. They are a means of identifying risks. More harm than good results from ignoring mistakes. Incident reports improve the management and treatment of patients by identifying high-risk patterns and initiating in-service programs to prevent future problems. These forms also make all the facts about an incident available to the facility in case of litigation. Increasingly, facilities use paperless computer-based reporting systems that are secure, timely, efficient, and effective. These may also offer online help and formal education and serve as a valuable tool for data analysis. The nurse responsible for a potential or actual harmful incident or who witnesses an injury is the one who completes the incident form. This form should contain the complete name of the person or people involved and the names of all witnesses; a complete factual account of the incident; the date, time, and place of the incident; pertinent characteristics of the person or people involved (e.g., alert, ambulatory, asleep) and of any equipment or resources being used; and any other variables believed to be important to the incident. Sentinel Events The Joint Commission's Sentinel Event Policy defines a sentinel event as an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase "or the risk thereof" includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. Such events are called "sentinel" because they signal the need for immediate investigation and response. Some examples of sentinel events are wrong-side surgery, suicide, and operative and postoperative complications. Accredited organizations are expected to identify and respond appropriately to all sentinel events occurring in the organization or associated with services that the organization provides or provides for. Appropriate response includes a thorough and credible root cause analysis, implementation of improvements to reduce risk, and monitoring of the effectiveness of those improvements. Root cause analysis involves digging progressively deeper into the event, repeatedly asking why the event occurred, and exploring the circumstances that led to it to determine where improvements can be made. Nurses play a critical role in responding to sentinel events. Never Events In 2011, the National Quality Forum released a newly revised list of 29 events that they termed "serious reportable events": extremely rare medical errors that should never happen to a patient. Often termed "never events," these include errors such as surgery performed on the wrong body part or on the wrong patient, leaving a foreign object inside a patient after surgery, or discharging an infant to the wrong person. By reporting and following suggested guidelines when a never event occurs, the likelihood of such an error happening again is greatly decreased. There is growing consensus that hospitals should not be reimbursed for the treatment of the consequences of never events. The Leapfrog Group, a voluntary program aimed at recognizing and rewarding big leaps in health care safety, quality, and customer value, gives public recognition to hospitals if they agree to the following when a never event occurs within their facility: - Apologize to the patient and family - Waive all costs related to the event and follow-up care - Report the event to an external facility - Conduct a root cause analysis of how and why the event occurred

Additional Terms Used to Describe Urinary Problems

Anuria: 24-hour urine output is less than 50 mL Dysuria: Painful or difficult urination Frequency: Increased incidence of voiding Glycosuria: Presence of glucose in the urine Nocturia: Awakening at night to urinate Oliguria: 24-hour urine output is less than 400 mL Polyuria: Excessive output of urine (diuresis) Proteinuria: Protein in the urine Pyuria: Pus in the urine Urgency: Strong desire to void Urinary incontinence: Involuntary loss of urine

Develop nursing diagnoses that identify bowel elimination problems amenable to nursing intervention.

Diarrhea Possible Related/Risk Factors (R/T) -Adverse effects of pharmaceutical agents -Abuse of laxatives -Emotional stress -Intestinal infection -Colon disease and other diseases -Radiation Sample Defining Characteristics/As Evidenced By (AEB) • At least three loose, liquid stools per day, increased frequency • Urgency • Reports of abdominal pain and/or cramping • Hyperactive bowel sounds Bowel Incontinence -Possible Related/Risk Factors (R/T) -Dietary habits -General decline in muscle tone -Laxative abuse -Rectal sphincter abnormality -Cognitive impairment Sample Defining Characteristics/As Evidenced By (AEB) • Involuntary passage of stool (stool characteristics vary) • "I'm sorry, I couldn't get into the bathroom (or onto the bedpan) quickly enough." • "It came so fast I couldn't hold it back." • Constant dribbling of soft stool Risk for Constipation Possible Related/Risk Factors (R/T) -Insufficient fluid intake -Insufficient fiber intake -Inactivity -Delaying defecation when urge is present -Abuse of laxatives

Ethics

Ethics: is a systematic study of principles of right and wrong conduct, virtue and vice, and good and evil as they relate to conduct and human flourishing. - The ability to be ethical, to make decisions and act in an ethical manner, begins in childhood and develops gradually.

Identify variables that influence urination.

Developmental Factors Food & Fluid Intake Psychological Variables Activity and Muscle Tone Pathologic Conditions Medications Developmental Factors Children - Toilet training 2 to 3 years old, enuresis Effects of aging o Nocturia o Increased frequency o Urine retention and stasis o Voluntary control affected by physical problem Food & Fluid Intake - When the body is functioning well, the kidneys help the body maintain a careful balance of fluid intake and output, which should be about equal. When the body is dehydrated, the kidneys reabsorb fluid. The urine produced is more concentrated and is decreased in amount. Conversely, with fluid overload, the kidneys excrete a large quantity of dilute urine. - Alcohol produces a diuretic effect by inhibiting the release of antidiuretic hormone, increasing urine production. Foods high in water may increase urine production. Foods and beverages with high sodium content cause sodium and water reabsorption and retention, thereby decreasing urine formation. Certain foods may affect the odor of the urine (asparagus, onions) or its color (beets). Psychological Variables - Many individual, family, and sociocultural variables influence a person's usual voiding habits. For some people, voiding is a personal and private act—something one does not talk about. Needing assistance with a bedpan or urinal may provoke great embarrassment and anxiety, especially when the bedpan is offered by a nurse of the opposite biological sex. For others, voiding is a natural act that does not cause embarrassment; these people readily excuse themselves to void whenever the urge presents. - Some people who experience stress void smaller amounts of urine at more frequent intervals. Stress can also interfere with the ability to relax the perineal muscles and the external urethral sphincter. When this happens, the person may feel an urge to void, but emptying the bladder completely becomes difficult or impossible. Activity and Muscle Tone - Among the many benefits of regular exercise are increased metabolism and optimal urine production and elimination. During prolonged periods of immobility, decreased bladder and sphincter tone can result in poor urinary control and urinary stasis. People with indwelling urinary catheters lose bladder tone because the bladder muscle is not being stretched by the bladder filling with urine. Other causes of decreased muscle tone include childbearing, muscle atrophy due to decreased estrogen levels as seen with menopause, and damage to muscles from trauma. Pathologic Conditions - Certain renal or urologic problems can affect both the quantity and the quality of urine produced. Diseases associated with renal problems include congenital urinary tract abnormalities, polycystic kidney disease, UTI, urinary calculi (kidney stones), hypertension, diabetes mellitus, gout, and certain connective tissue disorders. Renal failure is a condition in which the kidneys fail to remove metabolic end products from the blood and are unable to regulate fluid, electrolyte, and pH balance. Acute kidney injury (AKI), also called acute renal failure, is a sudden decline in kidney function, and may be caused by conditions such as severe dehydration, anaphylactic shock, sepsis, and ureteral obstruction. Chronic kidney disease (CKD) is the slow loss of kidney function over months or years as a result of irreparable damage to the kidneys. CKD is caused by conditions such as diabetes, hypertension, and glomerulonephritis. Progression of CKD will eventually lead to the final stage of CKD, known as end-stage renal disease (ESRD) or kidney (renal) failure. In ESRD, the kidneys are unable to adequately excrete metabolic waste and regulate fluid and electrolyte balance - Diseases that reduce physical activity or lead to generalized weakness, such as arthritis, Parkinson's disease, and degenerative joint disease, may interfere with toileting. Cognitive deficits and certain psychiatric problems can interfere with a person's ability or desire to control urination voluntarily. Fever and diaphoresis (profuse perspiration) result in body fluid conservation by the kidneys, in which urine production is decreased, and the urine is highly concentrated. Other pathologic conditions, such as heart failure, may lead to fluid retention and decreased urine output. High blood glucose levels, such as with diabetes mellitus, may lead to an increase in urine output secondary to an osmotic diuretic effect. Medications - Medications have numerous effects on urine production and elimination. Of gravest concern are the many prescription and nonprescription drugs known to be nephrotoxic (capable of causing kidney damage). - Abuse of analgesics, such as aspirin or ibuprofen, can cause nephrotoxicity. Some antibiotics, such as gentamicin, can be nephrotoxic as well. - Diuretics, which commonly are used in the treatment of hypertension and other disorders, prevent the reabsorption of water and certain electrolytes in the tubules. Depending on the dose of the drug, diuretics cause moderate to severe increases in production and excretion of dilute urine. - Cholinergic medications stimulate contraction of the detrusor muscle and produce urination. Some analgesics and tranquilizers suppress the central nervous system, interfering with urination by diminishing the effectiveness of the neural reflex. Certain drugs cause urine to change color, including the following: - Anticoagulants may cause hematuria (blood in the urine), leading to a pink or red color. - Diuretics can lighten the color of urine to pale yellow. - Phenazopyridine, a urinary tract analgesic, can cause orange or orange-red urine. - The antidepressant amitriptyline or B-complex vitamins can turn urine green or blue-green. - Levodopa (L-dopa), an antiparkinson drug, and injectable iron compounds can lead to brown or black urine.

Identify variables that influence bowel elimination

Food, Fluid, Activity, Lifestyle, Psychological variables, Pathologic conditions, Medications, Diagnostic studies, surgery/anesthesia Age: - Infants: Characteristics of stool and frequency depend on formula or breast feedings. - Toddler: Physiologic maturity is the first priority for bowel training. - Child, adolescent, adult: Defecation patterns vary in quantity, frequency, and rhythmicity. - Older adult: Constipation is often a chronic problem; diarrhea and fecal incontinence may result from physiologic or lifestyle changes. Food: - Constipating foods: cheese, lean meat, eggs, pasta - Foods with laxative effect: fruits and vegetables, bran, chocolate, alcohol, coffee - Gas-producing foods: onions, cabbage, beans, cauliflower Psychological Variables: - Psychological stress affects the body in many ways. In some people, anxiety seems to have a direct effect on gastrointestinal motility, and diarrhea accompanies periods of high anxiety. In the fight-or-flight response, when the body mobilizes itself for intense action, blood is shunted away from the stomach and intestines, resulting in a slowing of gastrointestinal motility. People who chronically worry and those with certain personality types who tend to hold onto problems and negative feelings may experience frequent constipation. Medication: - Aspirin, anticoagulants: pink to red to black stool - Iron salts: black stool - Bismuth subsalicylate used to treat diarrhea can also cause black stools. - Antacids: white discoloration or speckling in stool - Antibiotics: green-gray color Medications are available that can promote peristalsis (laxatives) or inhibit peristalsis (antidiarrheal medications). Diagnostic Studies - Diagnostic studies may affect a patient's usual bowel elimination pattern. For example, patients may need to fast for diagnostic studies. The ingestion of barium during diagnostic procedures, such as a barium enema, may result in constipation or impaction if it is not completely eliminated after the procedure. In addition, the stress of hospitalization and waiting for the results of studies, combined with changes in food intake, can severely alter a patient's usual elimination patterns. The bowel preparation used for bowel cleansing before certain diagnostic studies of the gastrointestinal tract can interfere with the normal timing of a patient's bowel movements. Surgery and Anesthesia - Direct manipulation of the bowel during abdominal surgery inhibits peristalsis, causing a condition termed postoperative paralytic ileus. - This temporary stoppage of peristalsis normally lasts 3 to 5 days. During this time, food and oral fluids are usually withheld. Many times, the patient is receiving opioids for pain relief, which can exacerbate the situation. If this condition persists, distention and symptoms of acute obstruction may occur, possibly resulting in the need for surgical intervention. Inhaled general anesthetic agents also inhibit peristalsis by blocking the parasympathetic impulses to the intestinal musculature. However, local and regional anesthetics have little effect on peristalsis.

Recognize ethical issues as they arise in nursing practice

Paternalism - An alert older resident who lives in a long-term care facility and who is now at high risk for falls refuses to call the nurse for assistance when getting out of bed. The nurse must decide whether to obtain an order to restrain the patient. Does preventing potential harm justify violating the patient's right to autonomy and make it acceptable for the nurse to act as a "parent," choosing an action the patient does not want because the nurse believes it to be in the patient's best interest? Deception - A postoperative patient asks the student nurse, who is about to administer an intramuscular injection for pain, "Is this your first shot?" It does happen to be the student's first injection, and the student is anxious. Would the student's intent to decrease the patient's anxiety justify telling the patient, "No, I've given several before"? Privacy and Social Media - A nursing student in your class shows you her recent Facebook posting that includes a photo of a patient with a large sacral pressure injury. She says that since the patient is lying face down, this is not an invasion of privacy. What patient information can you post ethically on social media sites? How would you respond? Be familiar with guidelines for use of social media issued by the NSNA, ANA, and the National Council State Boards of Nursing. See more on social media in Chapters 7 and 20. Confidentiality - A nurse asks a middle-aged woman who is crying quietly, "Would you like to share what's troubling you?" The woman tells the nurse that she has no idea how she will pay for this clinic visit because she entered the country illegally 2 months ago and is trying to earn enough money to help her family back home. She begs the nurse not to tell anyone. If the nurse believes that this anxiety is interfering with the patient's ability to obtain needed health care, would it be ethical to break the woman's confidence to obtain help for her? Allocation of Scarce Nursing Resources - A nurse has just been pulled from your unit, leaving it understaffed. Among your patients is a 33-year-old man recovering from a heart attack who is being discharged in the morning (he tells you that he still has many questions); an older adult who is close to death; and a woman with cancer who has been vomiting all day and who is in severe pain. You know that you cannot meet everyone's needs well. How do you "distribute" your nursing care? (You really like the patient who is going home in the morning.) Valid Consent or Refusal - A resident is attempting to perform a spinal tap on an adolescent whom you know dislikes the resident. After one failed attempt, the adolescent tells the resident to stop. The resident asks you to administer an antianxiety medication to the patient to enable the resident to get the spinal tap done quickly. Should you administer the medication knowing that the patient no longer consents to the procedure? Conflicts Concerning New Technologies - An infertile woman asks you what you think about in vitro fertilization. She tells you that she is "desperate to produce a child for her husband and in-laws" but also has grave reservations about the whole process. "I've read about couples who end up with seven frozen embryos, and I think that would kill me, thinking I've got seven potential kids 'on ice.'" How do you respond? What informs your response? Unprofessional, Incompetent, Unethical, or Illegal Physician Practice - A nurse who works in the operating room notices that a pediatric surgeon who has been on the staff for several years and has done excellent work suddenly seems not to be concentrating during surgery and to be making more mistakes than usual. Rumors have been circulating about the surgeon having a problem with cocaine abuse after his recent divorce. The parents of one pediatric patient are dissatisfied with the progress the patient is making and ask the nurse for an opinion about the surgeon. Should the nurse voice personal concerns? Is the nurse ethically obligated to report the physician to the proper hospital authority for investigation? Unprofessional, Incompetent, Unethical, or Illegal Nurse Practice - When you make your morning rounds, a patient tells you that one of the nurses fondled her body and made suggestive remarks during the previous night shift. You suspect that the patient may simply be trying to cause trouble, and because you like the nurse in question, you find it hard to believe the patient. What should you do? Short Staffing Issues - Restructuring has resulted in chronic understaffing on the unit where you work. You believe that patients are now at risk because there simply are not enough nurses to provide quality care. Some nurses are talking about forming a union and going on strike. Because yours is the only major hospital in a rural area, you are unsure whether striking is a morally legitimate option. Because efforts to get management to address the issues have repeatedly failed, you are also contemplating "going public" with your concerns. Your brother works for the local newspaper, and he would be willing to do a story about the situation at the hospital. What do you do? Beginning-of-Life Issues - You are a psychiatric mental health nurse working in a Catholic hospital whose ethical and religious directives forbid abortion and abortion counseling. You are talking with a single woman recently hospitalized with bipolar disorder who is in the first trimester of an unplanned pregnancy and who is expressing great ambivalence about continuing the pregnancy. You personally believe that your ethical obligation is to assist this woman in exploring abortion as an option and to refer her to outside resources if she elects to abort. The charge nurse tells you that these are not appropriate conversations within this hospital. How do you reconcile your clinical obligations with your employee responsibilities? End-of-Life Issues - You are the nurse case manager for a woman with a history of cancer whose cancer has recurred after many years and is now seriously advanced. She frequently tells you when you come to visit her at home that she is unwilling to fight anymore and wants to die with some dignity while she is still in control. She begs you to get her something that will "put me gently to sleep once and for all before my pain gets worse." You believe that this is the woman's sincere wish, not just depression speaking, and you honestly believe that she would be better off spared the last stage of her fatal illness. According to your religious beliefs, however, assisted suicide is wrong under any circumstances. How do you reconcile your desire to help this woman with your profession's ethical code and your religious conviction that what she is asking for is wrong?

Describe the purposes of patient records

Patient records serve many purposes. The ANA states that the most important of these is "communicating within the health care team and providing information for other professionals, primarily for individuals and groups involved with accreditation, credentialing, legal, regulatory and legislative, reimbursement, research, and quality activities" Purpose is for: 1. Communication 2. Diagnostic and therapeutic orders 3. Care planning 4. Quality process and performance improvement 5. Decision Analysis 6. Research; decision analysis 7. Education 8. Credentialing, regulation, and legislation 9. Reimbursement 10. Legal and historical documentation

American Nurses Association Guidelines for Effective Communication

The ANA Standards identify the following characteristics of effective documentation: accessible; accurate, relevant, and consistent; auditable; clear, concise, and complete; legible/readable; thoughtful; timely, contemporaneous, and sequential; reflective of the nursing process; and retrievable on a permanent basis in a nursing-specific manner

Urinary Elimination Assessment Questions

Usual patterns of urinary elimination - How often do you urinate (pass your water) during the day? - Do you awaken at night to empty your bladder? - How would you describe your urine? Recent changes in urinary elimination - Have you noticed any changes in your usual urinary patterns (frequency, amount, force of stream, difficulty, comfort)? - Do you ever leak urine (e.g., on your way to the bathroom or when you sneeze or cough)? - Do you ever notice that your undergarments are wet or damp? Aids to elimination - Is there anything you do that helps you to urinate? Present or past occurrence of voiding difficulties (nature of problem, onset, frequency, causes, severity, symptoms, intervention attempted, results) - Tell me about any problems you are having now when you urinate (urgency, pain or burning, difficulty starting or stopping stream, dribbling, incontinence). - If there is a problem, describe what you feel like before you urinate and while you are urinating. - Have you had any urinary problems in the past (any history of urinary tract infections, kidney or bladder disease or problems)? - Do you use any type of absorbent pad or product to protect your clothes? Presence of urinary diversion (normal routine, history of problems) - Tell me about your usual routine with your ileal conduit.

SBAR

consistent, clear, structured, and easy-to-use method of communication between health care personnel; it organizes communication by the categories of: Situation, Background, Assessment, and Recommendations. ISBAR is an easy-to-remember, concrete mechanism useful for framing any conversation, especially critical ones, requiring a clinician's immediate attention and action. Situation. Create a brief statement of the problem. The word "brief" here is key. A big part of SBAR is removing irrelevant information. Make sure to identify yourself, your unit, and give the patient's name. Background. Give a concise overview of the situation. This may include diagnoses, medical history, dates, medication info, or names of physicians involved. Basically, anything that's relevant. Assessment. Sum up what you think is going on. Consider results of any lab tests. If you can't create a clear assessment, just say that. Recommendations. Clearly state what you're requesting. Be specific about suggested action and time frame. In verbal communication, repeat back any order for greatest accuracy. Making a recommendation can be as simple as saying, "I'd like you to check on this patient."

Describe the professional and legal regulation of nursing practice. Nurse Practice Acts, located in the Iowa Code

a. Nurse Practice Acts - most important law - laws established in each state and province to regulate the practice of nursing b. Standards set by the ANA - developed by a legislature and are implemented by authority by the state to determine minimum standards for the education of nurses c. Credentialing i. Accreditation - gives state responsibility for the public welfare. Ensures that nurses are meeting minimum standards. ii. Licensure - each state regulates the practice of safe and competent practice through licensure process - NCLEX-RN iii. Certification - validates special knowledge, experience, and clinical judgment. IN DEPTH: Standards - Voluntary standards, developed and implemented by the nursing profession itself, are not mandatory but are used as guidelines for peer review. Professional nursing organizations continually reassess the functions, standards, and qualifications of their members. These organizations are guided by their own assessment of society's need for nursing and by the public's expectations of nursing. Examples of voluntary standards include the American Nurses Association (ANA) standards of practice, professional standards for the accreditation of education programs and service organizations, and standards for the certification of individual nurses in general and specialty areas of practice. Legal standards, on the other hand, are developed by a legislature and are implemented by authority granted by the state to determine minimum standards for the education of nurses, to set requirements for licensure or registration, and to decide when a nurse's license may be suspended or revoked. Examples of legal standards include state nurse practice acts and rules and regulations of nursing. Credentialing - Nursing has taken several steps to ensure the competence of its health care providers, including the credentialing process. Credentialing refers to ways in which professional competence is ensured and maintained. Three processes are used for credentialing in nursing. The first is accreditation, which is the process by which an educational program is evaluated and recognized as having met certain standards. The second is licensure, which is the process by which a state determines that a candidate meets certain minimum requirements to practice in the profession and grants a license to do so. The third is certification, which is the process by which a person who has met certain criteria established by a nongovernmental association is granted recognition in a specified practice area. Accreditation - State constitutions give states a responsibility for the public welfare. State legislative bodies have used this principle to enact laws controlling occupational and professional groups. One function of these laws is to see that schools preparing health care providers maintain minimum standards of education. Nursing, like most other health care professions, operates under state laws that promote the general welfare by determining minimum standards of education through accreditation of schools of nursing. State-approved, or accredited, educational programs in nursing include practical or vocational, associate degree, diploma, baccalaureate, and graduate programs in nursing. Legal accreditation of a school preparing nursing personnel by the State Board of Nursing is different from voluntary accreditation. The National League for Nursing Accrediting Commission (NLNAC) and the American Association of Colleges of Nursing (AACN) are voluntary facilities that accredit schools when they meet certain criteria. Most schools choose to seek this voluntary accreditation, and many prospective students prefer selecting accredited schools. Accreditation by NLNAC or AACN is not a legal requirement for a school to exist; state accreditation is a legal requirement. Licensure - Licensure is a specialized form of credentialing based on laws passed by a state legislature. A license is a legal document that permits a person to offer to the public skills and knowledge in a particular jurisdiction, where such practice would otherwise be unlawful without a license. Licensure is discussed in Chapter 1. In addition to successfully completing an accredited nursing program of study and passing the National Council Licensure Examination (NCLEX), to maintain a license in good standing a nurse must meet other requirements as determined by the state or territory. These requirements typically include good moral character, continuing clinical competence or continuing education, the absence of a criminal record, English proficiency, and compliance with specific provisions of the state's nursing laws. Some states require criminal background checks. According to the NCSBN, a mutual recognition model of nurse licensure allows a nurse to have one license in his or her state of residency and to practice in other states (both physically and electronically) as well, subject to each state's practice law and regulation, unless otherwise restricted. This multistate nurse licensure model is governed by the Nurse Licensure Compact (NLC). All states that currently belong to the NLC also operate the single-state licensure model for those nurses who reside legally in an NLC state but do not qualify for multistate licensure. You must legally reside in an NLC state to be eligible for a multistate license. For questions related to the multistate license or privilege to practice, contact the Board of Nursing in your state of residence. Once earned, a license to practice is a property right and may not be revoked without due process. This includes notice of an investigation, a fair and impartial hearing, and a proper decision based on substantial evidence. Crucial to a nurse's successful defense are early legal counsel, character and expert witnesses, and thorough preparation for all proceedings. State Boards of Nursing may revoke or suspend a nurse's license or registration for various reasons. Drug or alcohol abuse is currently the most frequent reason. Other reasons for revocation or suspension of a license or registration include fraud, deceptive practices, criminal acts, previous disciplinary action by other state boards, gross or ordinary negligence, and physical or mental impairments, including those resulting from aging. Certification - Whereas licensure measures entry-level competence, certification validates specialty knowledge, experience, and clinical judgment. Nursing certification is offered by many U.S. professional organizations, including two primary organizations: the American Association of Critical-Care Nurses, which represents the specialty with the largest number of certified nurses, and the American Nurses Credentialing Center, a subsidiary of ANA, which began certifying nurses in 1974. The latter is the largest and most prestigious nurse credentialing organization in the United States and has certified more than a quarter million nurses since 1990. Although certification, which involves special testing, is voluntary, nurse specialists are increasingly becoming certified. Certification is one means to demonstrate advanced proficiency and a commitment to ensuring competence in the context of the current U.S. health care crisis, evidenced by daily reports of unsafe care, rising litigation, escalating costs, and a worsening nursing shortage.

Identify appropriate nursing interventions to promote regular bowel habits

- Timing - Positioning - Privacy - Nutrition - Exercise o Abdominal settings o Thigh strengthening TIMING - Encourage toileting at the patient's usual time during the day. Ask the patient to explain what measures are most successful in maintaining regular bowel function at home. Offer whatever assistance is needed to help the patient to the bathroom, commode, or bedpan at the time that a patient usually experiences the urge to defecate. This is often about an hour after meals, when mass colonic peristalsis occurs. Because many patients feel uncomfortable about requesting time for elimination, educate all patients about the importance of heeding this natural urge, as postponing it could result in constipation and other problems. POSITIONING - Sitting upright on a toilet or commode promotes defecation. Most patients who are able to use the bedside commode or bathroom toilet have little difficulty assuming this position, although they may need support. An elevated toilet seat may be ordered for patients with orthopedic problems who cannot lower themselves to a toilet seat. Sitting upright promotes a sense of normalcy and the effects of gravity help to promote regular bowel movements. Using a small step stool instead of resting the feet on the floor may improve defecation by straightening the anorectal junction and easing the evacuation of stool. - It is best to avoid bedpan use; encourage use of the toilet or bedside commode, as discussed previously. Patients who need to use a bedpan often benefit from having the head of the bed elevated to as close to a sitting position as possible, at least 30 degrees, unless this is contraindicated. An overhead trapeze may be helpful for patients with weak lower extremities. - Offer the patient moistened hand wipes at the bedside to substitute for handwashing after toileting. Always empty, clean, and return the bedpan to the patient's bedside stand or store according to facility policy. PRIVACY - Because most people consider elimination a private act, always respect the patient's need to be alone while defecating, unless the patient's condition makes this impossible. Pull the bedside drapes around a patient who is using a bedside commode or bedpan. If any visitors are present, ask them to step outside for a few minutes and alert other health care providers and hospital personnel. For well patients who cannot defecate in a public restroom (with multiple toilets) or strange environment, suggest that they use a private restroom with only one toilet. NUTRITION - Patients with bowel elimination problems may need a dietary analysis to determine which foods and fluids are contributing to their problem and which may help in its treatment. General dietary recommendations to promote regular defecation include a fluid intake of 2,000 to 3,000 mL and high-fiber intake. - Water is recommended as the fluid of choice because fluids containing large amounts of caffeine and sugar may have a diuretic effect. It is important to be aware of those patients, particularly older adults with cardiac and renal problems, for whom increased fluid intake may be contraindicated. Increasing fiber intake without sufficient fluid intake can result in severe gastrointestinal problems, including fecal impaction. Specific recommendations for treating constipation, diarrhea, and excessive flatulence follow. EXERCISE - Although there is conflicting evidence on the role exercise plays in eliminating constipation, it is known that regular exercise improves gastrointestinal motility and aids in defecation. - Encourage those patients who are able to exercise regularly for 2½ hours or more a week. It is important to get patients out of bed and walking as soon as they are able, instructing them that inactivity can lead to constipation, distention, and impaction. Bedside exercises may be helpful for patients who are immobile. Teach the following exercises to help patients with weak abdominal and perineal muscles who are using a bedpan: - Abdominal setting: The patient, lying in a supine position, tightens and holds the abdominal muscles for 6 seconds and then relaxes them. Repeat several times each waking hour. - Thigh strengthening: The thigh muscles are flexed and contracted by slowly bringing the knees up to the chest one at a time and then lowering them to the bed. Perform this exercise several times for each knee each waking hour.

Use appropriate legal safeguards in nursing practice.

- Competent practice - Informed consent or refusal - Contracts - Collective bargaining - Patient education - Executing physician orders - Delegating nursing care - Documentation - Appropriate use of social media - Adequate staffing - Whistle-blowing - Professional liability insurance - Risk management programs - Just culture - Incident, variance, or occurrence reports; sentinel events and Never events - Patients rights - Good Samaritan Laws - Student liability

Chapter 19 Key Concepts

- Effective communication among health care professionals is essential for coordination and continuity of care. The three forms of communication central to nurses' professional role are documenting, reporting, and conferring. - Documentation is the written or typed legal record of all pertinent interactions with the patient: assessing, diagnosing, planning, implementing, and evaluating. - The patient record is a compilation of a patient's health information. Each health care institution or facility has policies that specify the nurse's documentation responsibilities. - The American Nurses Association (ANA) identifies the following characteristics of effective documentation: accessible; accurate, relevant, and consistent; auditable; clear, concise, and complete; legible/readable (particularly in terms of the resolution and related qualities of electronic health record [EHR] content displayed on the screens of various devices); thoughtful; timely, contemporaneous, and sequential; reflective of the nursing process; and retrievable on a permanent basis in a nursing-specific manner. - All information about patients is considered private or confidential, whether written on paper, saved on a computer, or spoken aloud. - Professional codes of ethics, facility policies, and state and federal privacy legislation dictate how patient information can be communicated (verbally and in writing), where and how it can be stored, the appropriate people and entities to whom it may be divulged, and the purposes for which it may be divulged. Nurses must be familiar with these guidelines. - Most facilities have specific policies for patient records. Everyone with access to the record is expected to maintain its confidentiality. Most facilities grant student nurses access to patient records for education purposes, in which case the student assumes responsibility to hold patient information in confidence. - Students should minimize the use of abbreviations and instead write or type out the full terminology or name in order to create a clear record for the caregivers who follow. - Patient records serve many purposes. The ANA states that the most important of these is "communicating within the health care team and providing information for other professionals, primarily for individuals and groups involved with accreditation, credentialing, legal, regulatory and legislative, reimbursement, research, and quality activities." - With EHRs, data can be distributed among many caregivers in a standardized format, allowing them to compare and uniformly evaluate patient progress easily. Besides tracking the progress of individual patients, computerized outcome information can compare the progress of groups of patients with similar diagnoses. These results contribute to research, education, and improved and more efficient nursing practice. - An electronic health information exchange (HIE) allows doctors, nurses, pharmacists, other health care providers and patients to appropriately access and securely share a patient's vital medical information electronically—improving the speed, quality, safety, and cost of patient care. - The chief reason for creating a personal health record is to provide easy access to up-to-date, complete health information to assist in self-care and communication with providers. - A source-oriented paper record is one in which each health care group keeps data on its own separate form. Sections of the record are designated for nurses, physicians, laboratory, x-ray personnel, and so on. Notations are entered chronologically, with the most recent entry nearest the front of the record. - The problem-oriented medical record (POMR) is organized around a patient's problems rather than around sources of information. With POMRs, all health care professionals record information on the same forms. The advantages of this type of record are that the entire health care team works together to identify a master list of patient problems and contributes collaboratively to the plan of care. - Other documentation methods include SOAP (Subjective data, Objective data, Assessment [the caregiver's judgment about the situation], Plan); PIE—Problem, Intervention, Evaluation; focus charting; charting by exception (CBE); and case management model. - Formats for nursing documentation include the initial nursing assessment, care plan, patient care summary, critical/collaborative pathways, progress notes, flow sheets and graphic record, medication record, and acuity records. - At the time a patient is discharged from care or transferred from one unit or institution or facility to another, a discharge summary is written that concisely summarizes the reason for treatment, significant findings, the procedures performed and treatment rendered, the patient's condition on discharge or transfer, and any specific pertinent instructions given to the patient and family. - Special guidelines exist for home health care and long-term care documentation. - To report is to give an account of something that has been seen, heard, done, or considered. Reporting is the oral, written, or computer-based communication of patient data to others. - The trend is toward a standardized, streamlined shift report system at the bedside, which is driven by patient safety and enhanced patient/family participation. - An incident report, also termed a variance or occurrence report, is a tool used by health care facilities to document the occurrence of anything out of the ordinary that results in, or has the potential to result in, harm to a patient, employee, or visitor. These reports are used for quality improvement and are not intended to be used for disciplinary action against staff members. - When nurses detect problems they cannot resolve because the problems are outside the scope of independent nursing practice or nurses' expertise, they make consultations or referrals to other professionals.

Plan and provide nursing care for a patient with an ostomy

- Keep the patient as free of odors as possible; empty the appliance frequently. - Inspect the patient's stoma regularly. o Note the size, which should stabilize within 6 to 8 weeks. o Keep the skin around the stoma site clean and dry. - Measure the patient's fluid intake and output. - Explain each aspect of care to the patient and self-care role. - Encourage patient to care for and look at ostomy The following guidelines help to promote the ostomy patient's physical and psychological comfort: - Keep the patient as free of odors as possible. Empty an ostomy appliance that can be drained when it is approximately one third full, thereby reducing the risk of leakage and potential odor. Remove and change nondrainable pouches when they are half full. - Inspect the patient's stoma regularly. It should be dark pink to red and moist. A pale stoma may indicate anemia and a dark or purple-blue stoma may reflect compromised circulation or ischemia. Bleeding around the stoma and its stem should be minimal. Notify the primary care provider promptly if bleeding persists or is excessive, or if color changes occur in the stoma. - Note the size of the stoma, which usually stabilizes within 6 to 8 weeks. Most stomas protrude ½ to 1 in from the abdominal surface and may initially appear swollen and edematous. After 6 weeks, the edema has usually subsided. Depending on the surgical technique, the final stoma may be flush with the skin. Erosion of skin around the stoma area can also lead to a flush stoma. If an abdominal dressing is in place at the surgical incision, check it frequently for drainage and bleeding. The dressing is usually removed after 24 hours. - Keep the skin around the stoma site (peristomal area) clean and dry. If care is not taken to protect the skin around the stoma, irritation or infection may occur. A leaking appliance frequently causes skin erosion. Candida or yeast infections can also occur around the stoma if the area is not kept dry. - Measure the patient's fluid intake and output. Check the ostomy appliance for the quality and quantity of discharge. Initially after surgery, peristalsis may be inhibited. As peristalsis returns, stool will be eliminated from the stoma. - Record intake and output every 4 hours for the first 3 days after surgery. If the patient's output decreases while intake remains stable, report the condition promptly. - Explain each aspect of care to the patient and explain what the patient's role will be when beginning self-care. Patient teaching is one of the most important aspects of colostomy care and should include family members and/or people identified by the patient to include in care, when appropriate. Teaching can begin before surgery so that the patient has adequate time to absorb information. - Encourage the patient to participate in care and to look at the ostomy. Patients normally experience emotional depression during the early postoperative period. Help the patient cope by listening, explaining, and being available and supportive. A visit from a representative of the local ostomy support group may be helpful. Patients usually begin to accept their altered body image when they are willing to look at the stoma, make neutral or positive statements concerning the ostomy, and express interest in learning self-care. Appliances can be either drainable or closed. Empty a pouch that can be drained when it is one third full and replace it every 3 to 7 days, or whenever the seal comes away from the skin. Remove and change nondrainable pouches when they are half full. During the first 6 to 8 weeks after surgery, encourage the patient with an ostomy to avoid foods high in fiber (e.g., foods with skins, seeds, shells), as well as any other foods that cause diarrhea or excessive flatus, such as beans, cabbage, cauliflower, Brussels sprouts, and simple carbohydrates such as white flour and potatoes. By gradually adding new foods, the ostomy patient can progress to a normal diet. Urge patients to drink at least 2 quarts of fluids, preferably water, daily.

Math to remember

Any math under 1, has to have zero in front 0.5 is correct Morphine .5 is not correct 5.0 no trailing zero 5 is correct 5.0 is incorrect bc it looks like 50

Plan, implement, and evaluate nursing care related to select nursing diagnoses that involve bowel problems.

Assessing Assessment of the gastrointestinal tract and bowel elimination includes pertinent patient history, physical assessment, and diagnostic studies. Questions to ask: Usual patterns of bowel elimination - How often do you move your bowels? - Any special time of the day? - What does your stool look like: - Frequency - Time of day - Description of usual stool characteristics (amount, consistency, shape, color, odor) - Do you ever have to strain to move your bowels? - Have you ever had to remove hard stool with your finger to help you move your bowels? Aids to elimination - Do you use anything to help move your bowels? - Natural aids (liquids, food) - Pharmacologic aids (laxatives) - Enemas - Recent changes in bowel elimination - Have you noticed any changes in your stool recently? - Have your noticed any change in the color of your stool? - Have you noticed any blood in your stool? (May need to ask patient about color blindness.) - Have you noted a difference in the appearance of your stool (narrowing, presence of mucus)? Problems with bowel elimination - Are your bowels causing you any problem now? -- Nature of disturbance -- Onset and frequency -- Causes (physical: food and fluid intake, exercise status, history of surgery or illnesses influencing gastrointestinal tract; psychosocial; medicine related) --Severity --Symptoms -- Interventions attempted and results Presence of artificial orifices (normal routine, history of problems) - What is your usual routine with your colostomy or ileostomy? - Do you have any problems caring for your colostomy or ileostomy? - Are there activities you are no longer able to perform because of your colostomy or ileostomy? Physical Assessment ABDOMEN The sequence for abdominal assessment proceeds from inspection, auscultation, and percussion to palpation. Inspection and auscultation are performed before palpation because palpation may disturb normal peristalsis and bowel motility. Inspection Observe the contour of the abdomen, noting any masses, scars, or areas of distention. Auscultation Using the diaphragm of a warmed stethoscope, listen for bowel sounds in all abdominal quadrants, using a systematic, clockwise approach. - Significant findings include hypoactive bowel sounds, a diminished rate of sounds; hyperactive bowel sounds, intense with increased frequency; and absent or infrequent bowel sounds. Hypoactive bowel sounds indicate diminished bowel motility, commonly caused by abdominal surgery or late bowel obstruction. Hyperactive bowel sounds indicate increased bowel motility, commonly caused by diarrhea, gastroenteritis, or early/partial bowel obstruction. Decreased or absent bowel sounds, evidenced only after listening for 2 minutes or longer, signify the absence of bowel motility, commonly associated with peritonitis, paralytic ileus, and/or prolonged mobility Palpation Perform light palpation in each quadrant. Use warm hands and bend the patient's knees if possible ANUS AND RECTUM Perform a superficial examination each time you wash a patient's anal area or assist with bowel evacuation. - Inspection is used to assess the anal area, which normally has increased pigmentation and some hair growth. Assess for lesions, ulcers, fissures (linear break on the margin of the anus), inflammation, and external hemorrhoids (dilated veins appearing as reddened protrusions). Ask the patient to bear down as though having a bowel movement. Assess for the appearance of internal hemorrhoids or fissures. Normally, there is no protrusion of tissue. Observe for a fecal mass, which may distend the anus. Inspect the perineal area for areas of skin irritation or breakdown secondary to diarrhea or fecal incontinence. Diagnosing Nursing diagnoses for bowel elimination can be divided into two categories: Bowel elimination as the problem and bowel elimination as the etiology. Bowel Elimination as the Problem - When the analysis of assessment data points to a bowel elimination problem that can be prevented or resolved by independent nursing intervention, a nursing diagnosis is developed. If alterations in bowel elimination require new self-care behaviors—for example, colostomy management—Deficient Knowledge may be an appropriate nursing diagnosis. Bowel Elimination as the Etiology Problems of bowel elimination may also affect other areas of human functioning. In the nursing diagnoses that follow, problems of bowel elimination are the etiology for other problems: - Deficient Fluid Volume related to prolonged diarrhea - Impaired Skin Integrity related to prolonged diarrhea, fecal incontinence - Ineffective Coping related to inability to accept permanent ostomy Outcome Identification and Planning - Expected outcomes are derived from the actual or potential bowel elimination problems diagnosed. The goal is to maintain or restore optimum function related to bowel elimination, alleviate symptoms or side effects of disease or treatment, and to prevent complications. General patient outcomes are listed here. Actual patient outcomes should list specific behaviors and criteria individualized for the patient situation. The patient will: - Have a soft, formed bowel movement without discomfort - Explain the relationship between bowel elimination and dietary fiber, fluid intake, and exercise - Relate the importance of seeking medical evaluation if changes in stool color or consistency persist - Maintain skin integrity

Competent Practice

Competent practice remains the nurse's most important and best legal safeguard. Each nurse is responsible for making sure that his or her educational background and clinical experience are adequate to fulfill the nursing responsibilities delineated in the job description. Legal safeguards include the following: - Developing and maintaining interpersonal communication skills - Respecting legal boundaries of practice - Following institutional procedures and policies - "Owning" personal strengths and weaknesses; seeking means of growth, education, and supervised experience to ensure continued competence for new and evolving responsibilities - Evaluating proposed assignments; refusing to accept responsibilities for which you are unprepared - Keeping current in nursing knowledge and skills - Respecting patient rights and developing rapport with patients - Working within the facility to develop and support management policies - Keeping careful documentation Remember that the medical record is the best, and sometimes the only, available evidence if you have to defend your actions. Nurse attorney Edie Brous recommends the following: - Document all clinical observations and critical diagnostics. - Document conversations with other providers regarding patient issues. - Document which specific health care provider was notified of which specific concerns at what specific time. - Document that the chain of command has been engaged when necessary. - Make sure that the medical record reflects that you pursued your concerns to resolution. Competent practice includes developing sensitivity to common sources of patient injury, such as falls, restraints, and malfunctioning equipment, and then taking specific measures to prevent patient injury.

Develop nursing diagnoses that correctly identify urinary problems amenable to nursing therapy.

Impaired Urinary Elimination • Sensory motor impairment • Urinary tract infection • Anatomic obstruction • Postvoid residual of 450 mL via bladder scanner • "It hurts when I pass my water and I have to go every hour!" • "I have to get up frequently at night to urinate." Stress Urinary Incontinence • Weak pelvic muscles and structural supports • Patient reports involuntary leakage of urine with sudden movement, coughing, sneezing, and laughing. Risk for Urge Urinary Incontinence • Alcohol and caffeine consumption, fecal impaction, ineffective toileting habits

Differentiate between intentional torts (assault and battery, defamation, invasion of privacy, false imprisonment, fraud) and unintentional torts (negligence).

Intentional Torts ASSAULT AND BATTERY - Assault is a threat or an attempt to make bodily contact with another person without that person's consent. Battery is an assault that is carried out and includes willful, angry, and violent or negligent touching of another person's body or clothes or anything attached to or held by that other person. Forcibly removing a patient's clothing, administering an injection after the patient has refused it, and pushing a patient into a chair are all examples of battery. Threatening to do any of these actions if the patient does not cooperate is assault. If an aggressive patient threatens harm, only actions necessary for self-protection or the aid of another are permitted. Every person has the right to be free from invasion of his or her person, and adult patients who are alert and oriented have the right to refuse any treatment. The fact that treatment is desirable does not allow the nurse or health care provider to proceed without the consent of the patient or to go beyond the limits to which the patient has consented (see "Informed Consent or Refusal" within "Legal Safeguards for the Nurse"). DEFAMATION - Defamation of character is an intentional tort in which one party makes derogatory remarks about another that diminish the other party's reputation. Slander is spoken defamation of character; libel is written defamation. Defamation of character is grounds for an award of civil damages. Damages are awarded to the plaintiff based on the amount of harm done to the plaintiff. Nurses who make false or exaggerated statements about their patients or coworkers run the risk of being sued for slander or libel. A person charged with slander or libel may be found not liable if it can be proved that the statement was made not to injure another but was made for a nonmalicious, justifiable purpose. INVASION OF PRIVACY - The U.S. Supreme Court has interpreted the right against invasion of privacy as a constitutional right. The Fourth Amendment gives citizens the right of privacy and the right to be left alone. State courts have also strongly protected a patient's right to have information kept confidential. What is confidential? All information about patients is considered private or confidential, whether written on paper, saved on a computer, or spoken aloud. This includes patient name and all identifiers, such as address, telephone number, e-mail address, Social Security number, and any other personal information. It also includes the reason that the patient is sick or in the hospital, office, or clinic, the treatments the patient receives, and information about past health conditions. Protected health information may be found in the patient medical record, computer systems, telephone calls and voice mails, fax transmissions, e-mails that contain patient information, and conversations about patients between clinical staff. The Health Insurance Portability and Accountability Act (HIPAA) was finalized in 2002. Most facilities now require workers to undergo HIPAA training and to review and sign a confidentiality agreement when hired and at each performance review. As a student in a health care setting, you should discuss privacy guidelines with your instructor and nurse mentors. HIPAA ensures that patients have the following rights: -To see and copy their health record -To update their health record -To request correction of any mistakes -To get a list of the disclosures a health care institution has made independent of disclosures made for the purposes of treatment, payment, and health care operations -To request a restriction on certain uses or disclosures -To choose how to receive health information If a health institution wants to release a patient's health information for purposes other than treatment, payment, and routine health care operations, the patient must sign an authorization. Other disclosure of confidential information, such as inappropriately discussing a patient's problem with a third party, may be construed as invasion of privacy and may subject the nurse to liability. The nurse's intimate knowledge of the patient increases legal risk in this regard. The doctrine of privileged communication specifies that people in a protected relationship, such as a doctor and patient, cannot be forced, even during legal proceedings, to reveal communication between them unless the person who benefits from the protection agrees to it. State laws determine which relationships are protected by the privilege doctrine, and not all states privilege nurse-patient communication. HIPAA includes punishments for anyone caught violating patient privacy: Those who do so for financial gain can be fined as much as $250,000 or be jailed for up to 10 years. Even accidentally breaking the rules can result in penalties—and embarrassment—for you and your organization. Certain acts by nurses could constitute invasion of privacy, as the following examples illustrate: -Unnecessary exposure of patients while moving them through a corridor or while caring for them in rooms they share with others -Talking with patients in rooms that are not soundproof -Discussing patient information with people not entitled to the information (e.g., with the patient's employer or the press, or even the patient's family if not authorized to do so) -Pressing the patient for information not necessary for care planning -Interacting with the patient's family in ways not authorized by the patient -Using tape recorders, dictating machines, computers, and the like without taking precautions to ensure the patient's confidentiality -Preparing written or oral class assignments about patients without concealing their identity -Carrying out research without taking proper precautions to ensure the anonymity of patients Cybersecurity has become a top priority for all health care systems. Finn and Dion (2017a) recently wrote, "Just as nurses have been on the front lines of fighting disease and illness, they are now combatting cybercriminals trying to rob our patients of privacy, personal information, and identities. More than ever, nurses are required to perform a task—provide information security—that falls well outside their job description and for which they receive little training." Finn and Dion quote ANA president Pamela Cipriano, "Nurses' ethical practice commands the safeguarding of a patient's right to privacy and confidentiality including their data and information. By being vigilant and using best practices to secure devices and the flow of information, nurses protect patients and maintain their trust." At times, a person's right to privacy may conflict with other rights, such as the public's right to information. When in doubt about disclosing confidential information, consult the nursing supervisor, ethics committee, or public relations department of the institution. FALSE IMPRISONMENT Unjustified retention or prevention of the movement of another person without proper consent can constitute false imprisonment. For example, only a reasonable amount of restraint should be used in circumstances that warrant it. The indiscriminate and thoughtless use of restraints on a patient can constitute false imprisonment. Springer (2015) cautions that restraints must not be used for coercion, punishment, discipline, or staff convenience. Serious sanctions by the state health department, The Joint Commission, or both, may result from improper restraint use. Be sure to check your institution's restraint policy before attempting to restrain any patient. A person cannot be legally forced to remain in a health facility, such as a hospital, if that person is of sound mind, even when health care providers believe that the person should remain for additional care. Health facilities have special forms to use when a patient insists on being discharged against medical orders. The patient signs to indicate not holding the facility responsible for any harm that may result from leaving. People who are mentally ill may be committed to a psychiatric institution for treatment without their consent (involuntary commitment) only when it can be proved that they may be harmful to themselves or others. FRAUD Fraud is willful and purposeful misrepresentation that could cause, or has caused, loss or harm to a person or property. Misrepresentation of a product is a common fraudulent act. A person fraudulently misrepresenting himself or herself to obtain a license to practice nursing may be prosecuted under the state's nurse practice act. Also, misrepresenting the outcome of a procedure or treatment may constitute fraud. Nurses who report vital signs or other assessment data that they have not obtained are acting fraudulently. Unintentional Torts NEGLIGENCE AND MALPRACTICE Negligence is defined as performing an act that a reasonably prudent person under similar circumstances would not do or, conversely, failing to perform an act that a reasonably prudent person under similar circumstances would do. As the definition implies, an act of negligence may be an act of omission or commission. Malpractice is the term generally used to describe negligence by professional personnel. Reising (2012) identifies the following common categories of malpractice claims: - Failure to follow standards of care. EXAMPLE: You fail to follow the standards for administering insulin or other injectable medications. - Failure to use equipment in a responsible manner. EXAMPLE: You attempt to use a bariatric patient lift for the first time without getting help, and the patient falls. - Failure to assess and monitor. EXAMPLE: You fail to follow your hospital's standards for postoperative assessments after receiving a patient from the operating room, and response to a ruptured suture line is delayed. - Failure to communicate. EXAMPLE: You fail to communicate your concerns about an older adult patient being discharged home; she lives alone. The patient is soon rehospitalized because no provisions were made to secure the nursing care she needed after discharge. - Failure to document. EXAMPLE: You believe a patient is in danger of arresting, but your repeated calls to a health care provider to see the patient are ignored, so you work up the chain of command. Before any health care provider sees the patient, he arrests and, despite a code, dies. You document the arrest, code, and death; however, you failed to document all the steps you took to get the patient the medical attention he needed. Sixteen months later, the family sues, and you try to remember what action you took that evening—most of which was never recorded. - Failure to act as a patient advocate or to follow the chain of command. EXAMPLE: You are in the operating room and watch a surgeon break the sterile field twice. No one else seems to notice. You are intimidated by this surgeon and fail to bring this to anyone's attention. You learn that the patient developed a serious infection postoperatively. ELEMENTS OF LIABILITY Liability involves four elements that must be established to prove that malpractice or negligence has occurred: duty, breach of duty, causation, and damages. Duty refers to an obligation to use due care (what a reasonably prudent nurse would do) and is defined by the standard of care appropriate for the nurse-patient relationship. Breach of duty is the failure to meet the standard of care. Causation, the most difficult element of liability to prove, shows that the failure to meet the standard of care (breach) actually caused the injury. Damages are the actual harm or injury resulting to the patient. STANDARDS OF CARE Whether negligence has occurred depends on a standard of care: what a reasonably prudent person would or would not have done under similar circumstances. All nurses are responsible for following the standards of care for their particular areas of practice. For example, labor and delivery nurses must understand how standards for nursing practice differ from those for medical obstetric practice (according to the state's nurse practice act); must be familiar with specific standards for obstetric nursing (e.g., Association of Women's Health, Obstetrics, and Neonatal Nursing [AWHONN]); and must carry out the nursing responsibilities detailed in the hospital's policies and procedures and in their job description. If hospital policy dictates an assessment of each woman in the early stages of labor every 30 minutes, for example, nurses must adhere to this standard unless they document a reason for doing otherwise.

Safeguards to Competent Practice

- Developing interpersonal communication skills - Respecting legal boundaries of practice - Following institutional procedures and policies - Owning personal strengths and weaknesses - Evaluating proposed assignments - Keeping current in nursing knowledge and skills - Respecting patient rights and developing rapport with patients - Keeping careful documentation - Working within agency for management policies

Student Liability

As a student nurse, you are responsible for your own acts, including any negligence that may result in patient injury. Moreover, you are held to the same standard of care as an RN. You are also responsible for being familiar with facility policies and procedures. Your legal responsibilities include careful preparation for each new clinical experience and a duty to notify your clinical instructor if you feel in any way unprepared to carry out a nursing procedure. For no reason should you attempt a clinical procedure if you are unsure of the correct steps involved.

Informed Consent or Refusal

Every person is granted freedom from bodily contact by another person unless consent is granted. In most states, you must be 18 to legally provide medical consent. States vary in the types of medical treatment they allow minors to authorize without their parents' consent; be sure to check your state law. In all health care facilities, informed and voluntary consent is needed for admission, for each specialized diagnostic or treatment procedure, and for any experimental treatments or procedures. The consent must be written, designated for the procedure to be performed, and signed by the patient or person legally responsible for the patient. A signed consent is not needed in an emergency if there is an immediate threat to life or health, if experts would agree that it is an emergency, and if the patient is unable to consent and a legally authorized person cannot be reached. While informed consent is a protection against lawsuits, the central values underlying informed consent include promoting the patient's well-being and respecting the patient's self-determination (President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, 1982). For this reason, you should make sure that patients have all the information they need, and that they understand the information, in order to validly consent to or refuse what is being proposed. Patients who do not speak English require the services of a translator; be sure to check your facility's policies about translation and be familiar with resources. Using a family member to translate is rarely acceptable. Similarly, patients with low literacy may be unable to read what they are signing and require extra help. Elements of informed consent include disclosure, comprehension, competence, and voluntariness (Box 7-5). Obtaining informed consent is the responsibility of the person who will perform the diagnostic or treatment procedure or the research study. Your role as a nurse is to confirm that a signed consent form is present in the patient's chart and to answer any patient questions about the consent. Unless you are obtaining consent for a nurse-prescribed and nurse-initiated intervention, as a nurse you sign the consent form as a witness to having seen the patient sign the form, not as having obtained the consent yourself (Fig. 7-2 on page 134). In some instances, you may be responsible for having a patient sign the consent form after a clinician has explained the procedure, its risks and benefits, and alternative treatments to the patient. Increasingly, nurses are performing procedures requiring consent, or are part of interdisciplinary teams that meet with the patient to obtain consent for complex interventions (e.g., bone marrow transplantation). Documenting the consent process with a printed consent form should not be confused with the actual explanation given to the patient and the informed consent itself. When documenting consent, assess whether patients understand what they are signing and are acting voluntarily, and report any problems to the clinician doing the procedure. Having patients describe in their own words what they understand they are consenting to is the best way to make sure that they understand. Nurses often question the patient's understanding of the proposed procedure and its risks or the patient's ability to consent voluntarily to the procedure. Impediments include the effects of anxiety, pain, medication, depression, language barriers, and temporary or permanent states of disorientation and confusion. Consequences of not obtaining a valid consent include the possibility of charges of battery against the nurse, the doctor, and the health care facility, which has a duty to protect patients and is responsible for its employees' actions. A patient's refusal to sign a consent form should be documented, and the patient should be informed of the possible consequences of the refusal. The patient should sign a release form indicating his or her refusal to consent and releasing the nurse, health care provider, and facility from responsibility for outcomes of this act. This statement should be witnessed.

Appropriate Use of Social Media

Social media have created new opportunities for defamation and violation of a patient's privacy and confidentiality rights. Be familiar with guidelines for use of social media issued by the National Student Nurses' Association, ANA, and the National Council State Boards of Nursing. Inappropriate use of social and electronic media may be reported to a State Board of Nursing. If the board finds the allegations to be true the nurse may face disciplinary action by the board, including a reprimand or sanction, assessment of a monetary fine, or temporary or permanent loss of licensure. If a nurse's improper use of social media violates state and federal laws established to protect patient privacy, the violations may result in both civil and criminal penalties, including fines and possible jail time. Nurses may also face employment consequences, including termination

Patient Education

U.S. courts affirm the patients' right to know what is necessary to manage their health, and view patient education as a legal duty of the nurse. Standards for patient education are derived from national professional standards and from state nurse practice acts as well as the local standards described in facility policies, procedure manuals, and job descriptions. Special forms for documenting the nurse's assessment of the patient's learning needs and for subsequent teaching are available in some facilities. Failure to conduct or document an assessment of a patient's learning needs and teaching may later be construed as negligence. Determine in your practice setting what specific aspects of patient education are the responsibility of nursing. Consult your job description, and be familiar with facility policies regarding patient education and its documentation. Remember that an important aim of nursing is to assist patients in managing their own care. Discuss the nursing care plan with patients and family members, and identify their learning needs and learning readiness. Document the teaching plan as part of the nursing care plan. Document all nursing efforts to educate the patient and family about health care management, and also document the patient's response. If a patient refuses health education or refers you to a family member (e.g., "Talk to my wife about my pills; she'll be giving them to me at home"), document this in the patient's record. If patient education greatly increases the patient's anxiety and the patient requests not to be given any more information, document the patient's initial response to teaching, the patient's request that it be stopped, and, if you complied, your reason for doing so. Because a lack of time is frequently offered as the reason for failing to document patient education, assess what type of patient documentation is performed routinely in your setting. If possible, develop forms or checklists that will facilitate rapid documentation. For example, preoperative checklists make it easy to record preoperative teaching and are often introduced as evidence in court that preoperative teaching was done. Similarly, other forms have been developed for documenting diabetic patient teaching, teaching after a myocardial infarction, and teaching postpartum and baby care to mothers.